Anamnesis

- by Stacey Prince

I learned this beautiful word today while reading the book Cutting for Stone (which, by the way, is a great read so far). In addition to having a lovely sound, like a sea creature or a generative biological process of some kind, anamnesis (from the Greek word for “remembrance”) has the following three interesting and varied definitions:

• The remembering of things from a supposed previous existence,
• A patient’s account of a medical history, and
• The part of the Eucharist in which the Passion, Resurrection, and Ascension of Christ are recalled.

Wow! A recollection, a patient’s self-reported medical history, and a Catholic sacrament all in one! What fascinating word. What it got me thinking about, though, was particularly the middle definition, “a patient’s account of a medical history”. Think about how important that is to all of us who are healers and providers of health care. Whether you are a massage therapist, an internal medicine specialist, or a psychotherapist, careful collecting of the patient’s medical history is critical both to accurate diagnosis and effective treatment planning. In Cutting for Stone the physician narrating the story recalls the words of her professor: “Milk the history! Exactly when and exactly how did it start? Onset is everything! In the anamnesis is the diagnosis!”

So, in the anamnesis is the diagnosis. Yet now think about how incredibly culture-bound this taking of the patient’s history is. Whether you are patient or caregiver, what you look for in tracing the origins and history of your pain, your symptoms, your distress is bound by what you have been taught to look for, what likely etiologies and processes and mechanisms your cultural context has provided you with. In your search for an explanation, you include some pieces of information and exclude others based on these cultural boundaries. A great example of this is the book The Spirit Catches You and You Fall Down, in which a young Hmong woman born in the US shortly after her family’s immigration is thought to have epilepsy and to need medication or surgery by her Western physicians, while members of her family believe she is possessed by spirits and needs shamanistic intervention and sacrifices. Told with compassion and balance, the author depicts the struggle to define her illness which leads to disastrous consequences as she is denied the benefit of both perspectives.

Now, think about how social justice and inequities come into play. Who defines the cultural boundaries, who gets to determine what is normal, what is pathological, what causes distress? Primarily those who hold privilege and are members of dominant groups. Those who hold this fearsome power differ by culture, of course, but in Western culture they are primarily highly educated with advanced degrees, often male, often White, and almost always owning class. While members of an individual’s community may have their own set of explanations for illness or distress, if they are not in power their explanations of their own or their family member’s illness may not prevail and will have little bearing on diagnosis and treatment of the individual in question.

So, here is a place where social justice and healing come together in ways that have profound and lasting impacts for individuals. Look at how the course of a person’s life can be altered by the ways that their medical histories are defined by those in power. A recent series on CNN explored reparative or conversion therapy, efforts (usually through aversive behavioral means) to change an individual’s sexual orientation from gay or lesbian to heterosexual. In “The Sissy Boy Experiment,” Anderson Cooper explores the history of such efforts to change sexual orientation. He focuses on the tragic story of one individual treated with conversion therapy as a youth by George Rekers, one of the leading proponents of conversion therapy. Initially deemed a “success” by Rekers, this young man by all reports led a terribly unhappy life and then committed suicide at age 38. His family members firmly believe that conversion therapy, which included both verbal and physical punishment for feminine behavior, was to blame.

Imagine such a patient’s anamnesis. He might tell you that he is unhappy and depressed because he is gay. This is what he has been told – by his church, the media, his family, and his doctor. In this cultural context he likely would be unable to recognize that there is a confounding variable, homophobia (and its internalized version), that might better explain both his own low self-esteem, feelings of unworthiness and depressive symptoms and other peoples’ opinions about him. Seeking treatment, he might then feel hopeless and suicidal because the treatment failed to change him. Ultimately, this internalizing, self-blaming anamnesis leads him to see no alternative but to take his life. How many young men and women have similar stories?

How could this narrative be different? Certainly the patient’s own anamnesis would need to be different. I see this process often in therapy, as my clients who struggle with substance abuse, social anxiety, and feelings of worthlessness begin to relate their symptoms to rejection by family or church, harassment, and constantly feeling the need to hide their identity and their relationships. A light bulb goes off, and suddenly there is a chance for hope, where before there was despair.

But even more than that, the cultural definition of homosexuality as an illness, a problem, and a deviation from the norm would need to change. Because even if a client’s anamnesis is transformed – even if he is able to say to his treatment providers, hey, I’m absolutely fine with being gay, it’s other people’s homophobia that’s causing my distress, that won’t be enough if his providers have a different story. Unfortunately, some practitioners continue to use conversion therapy despite the preponderance of evidence indicating that such treatment has little lasting effect on sexual orientation and can cause depression, anxiety, and suicidality, and despite the fact that numerous professional organizations including the American Psychological Association have deemed it unethical and harmful. Even among those practitioners who do not practice this abusive and overtly heterosexist form of therapy, biases and microaggressions based on sexual orientation still take place all too often (see for example my recent blog article reviewing research on this topic). Problem is, these same institutions of power that are now deeming conversion therapy and sexual orientation microaggressions unethical only stopped defining homosexuality as a mental illness a short 38 years ago.

Now a new but painfully familiar battle is being fought over the definition of acceptable gender identities. In our strict Western binary in which only “male” and “female” are acceptable categories, individuals who define themselves as both, or neither, or whose internal gender experience does not match their biological sex and who decide to transition, are still deemed by many to be deviant. They often cannot even receive treatment without receiving a diagnosis of “Gender Identity Disorder” (previous TJP blog article Transcending Diagnoses provides more information about the struggle to change this diagnosis and its criteria in the next version of the DSM; see also this recent article from The Bilerico Project in which the proposed DSM-V diagnosis “Gender Dysphoria” is discussed.) Yet how culture bound this is! This map shows the many places around the globe where gender is not constricted by the binary, where genders other than male and female are honored and not pathologized. This interactive map is fascinating and full of information; I hope you’ll take a look. Yet these individuals and cultures are generally not at the table when the folks in charge determine Western definitions of “normal,” so transgender individuals in our country are still harassed, discriminated against, and denied crucial medical and social services. The third segment of “The Sissy Boy Experiment” draws a clear parallel between conversion therapy and efforts to change gender identity in children who exhibit cross-gender behaviors.

While I have been focusing on sexual orientation and gender identity, an individual’s anamnesis is similarly impacted, interpreted and distorted when we look at ethnicity. What is defined as normal is largely defined by White, middle class, Western, Eurocentric men. So, for example, being emotionally expressive, relationally focused, and angry are all deemed unhealthy, while being logical, autonomous, calm and detached are seen as normative. It infuriated me when on a recent episode of “So You Think You Can Dance” a Black krumper who was clearly at the top of his game but expressed a lot of anger (both in his words and in his dance) was sent home, while another Black break dancer who in my humble opinion was no more talented or proficient in his style was sent through to the next round of competition. The latter young man was smiling, humble, a little obsequious, and deemed “adorable” by the judges, while the former was reprimanded for his arrogance and “frustration”. Not only was this a great example of the ways that personal discrimination can lead to systematic access to or denial of resources, since being on this show and advancing to later stages of the competition can lead to jobs and opportunities, but it also seemed to indicate a lack of understanding (or denial?) by the judges regarding the style of dance, krumping, demonstrated with great proficiency by the first dancer. Krumping IS about anger – at injustice, at racism, at systemic oppression. It’s a street dance giving the dancer a way to express anger, rage and frustration in a non-violent way. So to critique a krumper for being angry is, well, sort of missing the point. Also notable on this particular evening was the fact that the judging panel that night was all white; I wished there was one person of color, or one white ally, to argue with the head judge (a white, British, middle aged male executive producer) in favor of keeping the krumper for another round.

So in the end, I guess I agree with the quote from Cutting for Stone, but only with a big IF. “In the anamnesis is the diagnosis” - but only IF both the teller and listener are not bound by culturally prescribed definitions of health. Otherwise, the definitions of the dominant paradigm will prevail.